Personal Information Form

McCombs Funeral Home, Inc - Personal Information Submission Form
Decedent's Legal Name - First, Middle, Last, Suffix: (Please include A.K.A's if any)
Sex
If Female, Last Name Prior to Marriage
Date/Time of Death

MonthDayYear
Age
Date/Time of Birth

MonthDayYear
Birth Place: City
Birth Place: State
Birth Place: Country
Social Security Number
Decedent Served In U.S.Armed Forces
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County
Inside City Limits?
Marital Status At Time Of Death
Surviving Spouse's Name (If wife, give name prior to first marriage)
Father's Name (First, Middle, Last, Suffix)
Mother's name prior to first marriage (First, Middle, Last, Suffix)
Contact Person's Name
Contact Person's Relationship
Contact's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact's Phone Number

Area CodePhone Number
County Of Death
Did Death Occur In Hospital
If so:
If Death Occured Somewhere Other Than Hospital:
If OTHER, please specify
Facility Name
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Facility Phone

Area CodePhone Number
Decedent's Highest Level of Education
Decedent's Race
Decedent's Origin
If Decedent is Retired, List Most Recent Occupation
Decedent's Occupation, be specific, list job title and company
Attach Decedent's Photo

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McCombs Funeral Home, Inc - Personal Information Submission Form